The practical side of managing integrated Community Case Management

Jhpiego presented its recent experiences in building iCCM onto an existing malaria program in Akwa Ibom State, Nigeria, during the American Society of Tropical Medicine and Hygiene meeting today.

Establishing Integrated Community Management of Malaria, Pneumonia and Diarrhea in Two Selected Local Government Areas, Akwa Ibom State, Nigeria

William Brieger, Bright Orji, Emmanuel Otolorin, Eno Ndekhedehe, Jones Nwadike

Many intervention studies have demonstrated that local volunteers practicing integrated Community Case Management (iCCM) can increase access to appropriate lifesaving interventions. These interventions are important for giving us confidence in community capacity, but key management questions remain on how to establish, manage and expand iCCM efforts in order to reach Roll Back malaria Targets and Millennium development Goals.

The Nigeria MIS 2010 revealed inappropriate treatment andpPoor community response to malaria interventions. Among children (less than 5 years) with fever 2 weeks preceding the survey, only 26% took any antimalarial and only 3.2% took an ACT. Malaria treatment was largely by presumptive diagnosis.

A initial management decision for iCCM is what combination of interventions will comprise a start-up package. Nigeria’s Malaria Plus Package includes 19 potential health interventions at the community level, but clearly a program could not afford, let along manage the simultaneous implementation of all 19.

Jhpiego had successfully piloted community directed interventions (CDI) for  malaria in pregnancy (MIP) control interventions. Further formative research in two selected Local Government Areas showed poor access to malaria treatment for all age groups due to distance from health facility, poverty, financial constraints, and perceptions of health services quality. Therefore, iCCM was added to CDI for MIP prevention to improve treatment access and coverage for all age groups.

Teamwork was a necessary part of the process to guarantee sustainability. This included Local Government Health departments, Technical Assistance from Jhpiego (affiliate of Johns Hopkins University), World Bank Booster Project in State Ministry of Health Malaria Unit, a core Training and Supervisory team from the Ministry and iCCM/Malaria Plus Package Guidelines from National Malaria Control Program.

Stakeholder Challenges posed management problems including State Program Manager’s skepticism that community members can perform RDTs correctly, Health facility workers’ poor acceptance of RDTs as opposed to using their clinical judgment, and provider’s reluctance to trust communities with antibiotics.

dscn1517-a.jpgHealth Facility Management Challenges were numerous including procurement problems as needed medicines come from different funding sources. There was difficulty in sourcing RDTs that come with ready and easy to use components.

Procurement and supplies of AMFm drugs were delayed due to cumbersome, delayed drug registration processes. Sharps and waste disposal for RDTs needed attention. Finally there were multiple statistics tracking registers, as no one register captures all the indicators – a burden M&E personnel.

Community Challenges started with the belief that ‘blood of someone alive cannot be buried’ such that disposing of RDT cassette by burial would mean burying the person alive. Community members perceived that person has malaria even if RDT is negative. Cpommunity volunteers requested for incentives and motivation as new tasks included.

Addressing Stakeholder Challenges we held Stakeholders consensus meetings helped address reluctance by the health ministry to allow RDT use at the community level. Consensus meetings created an opportunity for programs to integrate as IMCI, RH and Malaria departments trained providers

Solving health facility management Challenges required that We work with other malaria partners to identify reliable sources of RDTs and drugs. Linking with a local pharmaceutical company already registered with AMFm helped fast tract supplies of ACTS.

eno-mobilizes-new-communities-2.jpgCommunity Dialogue was essential to overcome village concerns. Through dialogue the community agreed on incineration as an acceptable method of RDT disposal. Engaged communities accepted that only positive RDT-results need ACTs. Volunteers’ demands for incentives challenged by leaders who reminded the volunteers that they were accountable to their neighbors, friends and relatives in the village. Community self-monitoring was undertaken and two volunteers who did not deliver their ACTs were fined one-goat each by the community for failing to provide services.

Lessons Learned were foremost the need for consensus building among partners on roles and extent of services to be provided by volunteers. Continual community education and dialogue prior to the initial start-up iCCM provision and throughout is required. Without attention to these start-up processes we cannot expect to reach our endpoint coverage indicators and develop a scalable and sustainable program.

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